Donor Number: 240301

Health History:

Have you ever been pregnant? No

Do you have any children? No

Have you ever placed a child up for adoption? No

Any history of infertility in your family? No

Deliveries: N/A

#1: Date of delivery: Months trying to conceive:

Birth Weight: At how many weeks/days did you deliver? wks days

#2: Date of delivery: Months trying to conceive:

Birth Weight: At how many weeks/days did you deliver? wks days

#3: Date of delivery: Months trying to conceive:

Birth Weight: At how many weeks/days did you deliver? wks days

Date of last Pap Smear: Never had one done

Are you currently using birth control? No

Do you have a regular monthly menstrual cycle (every 21-35 days)? Yes

Do you smoke? No

Do you drink alcoholic beverages? No

Do you use recreational drugs? No

Are you currently taking any medications? No

Please describe any medical problems you have had: N/A

Have you or any of your biological relatives (including your parents, siblings, aunts, uncle, cousins and children) suffered from: (if yes, explain)

Physical birth defects? No

Down Syndrome? No

Mental Retardation? No

Ovarian Cysts? No

Uterine Fibroids? No

Asthma? No

Heart disease? No

Heart attack? No

Coronary artery disease? No

High blood pressure? No

Arrhythmia? No

High cholesterol? No

Atherosclerosis? No

Diabetes? No

Thyroid problems? Yes, Dads side of the family

Blood clotting disorder? No

Anemia? No

Learning disability/ies? No

Blindness? No

Hearing loss? No

Osteoporosis? No

Dwarfism? No

Huntington’s disease? No

Chronic heartburn? No

Alzheimer’s disease? No

Parkinson’s disease? No

Cerebral Palsy? No

Muscular Dystrophy? No

Seizure Disorder/Epilepsy? No

Cystic Fibrosis? No

Kidney disease? No

Any type of cancer? No

Seriously overweight? No

Multiple birthmarks? No

Alcoholism/heavy alcohol use? No

Recreational or prescription drug abuse? No

Been treated by a psychiatrist? No

Depression? No

Schizophrenia? No

Suicide attempt? No

Other mental illnesses? No